Negative emotions are related to poor performance in between-person analyses but facilitate performance in within-person analyses, under certain conditions. We examine the effect of situation contingent negative emotions (SCE) on performance, and trait neuroticism as a moderator of that relationship. SCE modelled negative emotions as responses to perceived task challenges using experience sampling data collected over three weeks (2453 responses). Performance was exam scores (n = 83) in an automotive engineering course. SCE predicted performance and this effect was moderated by trait neuroticism. SCE improved performance for students with lower neuroticism.

Pediatric PulmonologyVolume 56, Issue 6 p. 1386-1388 COMMENTARYFree Access Pediatric flexible airway endoscopy training during a pandemic and beyond: Bending the curve Albin Leong MD, ATSF, Department of Clinical Sciences, Pediatric Pulmonology, California Northstate University College of Medicine, Elk Grove, California, USASearch for more papers by this authorDan Benscoter DO, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USASearch for more papers by this authorJohn Brewington MD, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USASearch for more papers by this authorCherie Torres-Silva MD, MPH, MEd, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USASearch for more papers by this authorRobert E. Wood PhD, MD, Corresponding Author rewood@cchmc.org orcid.org/0000-0002-8137-9598 Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA Correspondence Robert E. Wood, PhD, MD, Cincinnati Children's Hospital Medical Center, MLC 7041, 3333 Burnet Ave, Cincinnati, OH 45229, USA. Email: rewood@cchmc.orgSearch for more papers by this author Albin Leong MD, ATSF, Department of Clinical Sciences, Pediatric Pulmonology, California Northstate University College of Medicine, Elk Grove, California, USASearch for more papers by this authorDan Benscoter DO, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USASearch for more papers by this authorJohn Brewington MD, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USASearch for more papers by this authorCherie Torres-Silva MD, MPH, MEd, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USASearch for more papers by this authorRobert E. Wood PhD, MD, Corresponding Author rewood@cchmc.org orcid.org/0000-0002-8137-9598 Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA Correspondence Robert E. Wood, PhD, MD, Cincinnati Children's Hospital Medical Center, MLC 7041, 3333 Burnet Ave, Cincinnati, OH 45229, USA. Email: rewood@cchmc.orgSearch for more papers by this author First published: 09 February 2021 https://doi.org/10.1002/ppul.25311AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat Flexible airway endoscopy, for diagnostic and therapeutic purposes, is a vital aspect of pediatric pulmonology practice and has become an integral aspect of formal training in pediatric pulmonology. Achieving competency in flexible airway endoscopy requires mastery of several skills, including cognitive (learning anatomy, recognition of pathology, etc.), and manual (manipulating the instrument safely and effectively, etc.). To acquire the cognitive and manual skills of flexible airway endoscopy, there is no adequate substitute for direct procedural experience with patients. In pediatric pulmonology, the opportunities for such experience vary widely among training programs, many of which can offer only limited experience. There are several potential barriers to training in pediatric bronchoscopy today. These include decreased procedure numbers due to the COVID-19 pandemic (and concerns for personnel safety); lack of access to centralized, formal training programs (also pandemic-related); and inadequacy of inanimate models and simulators for pediatric training. The COVID-19 pandemic caused by SARS-CoV-2 has resulted in significant disruption to health care, including medical training.1, 2 As this virus is primarily transmitted by respiratory droplets, aerosol-generating procedures, especially bronchoscopy, pose a special danger to health-care workers. Multiple adult bronchology societies have issued guidelines about the risk of bronchoscopy and protection of health-care workers during the COVID-19 pandemic. All the guidelines recommend limiting the personnel present during the procedure, including those on patients not suspected of COVID-19, as well as prioritizing and limiting elective bronchoscopies. These guidelines acknowledge relying on consensus due to limited evidence of studies during this new and evolving pandemic.3-5 The consequences of the pandemic include a potentially dramatic reduction in the opportunities for hands-on learning for pediatric pulmonology training. This could cause a significant educational gap for current fellows. In the setting of caution on scheduling and performing aerosol-generating procedures and consequently restricted opportunities for hands-on experience, how can trainees develop proficiency in performing bronchoscopy? For surgical resident training, several alternative approaches have been proposed, including remote training platforms with prerecorded lectures, online practice questions, teleconferencing and telemedicine, procedural simulation, surgical videos, and developing competency tests.6-8 A survey of training in pediatric flexible bronchoscopy in the United States published in 2014 revealed that the apprentice model, with volume-based ascertainment of competency, was the primary method utilized by pediatric pulmonology training directors.9 There are currently no evidence-based competency guidelines for pediatric flexible bronchoscopy. A suggested list of core competencies for pediatric flexible airway endoscopy is published in the Official ATS Technical Standards document.10 In addition, the Supplement to the Technical Standards lists some tools for online learning of clinical assessment and performance from the American Thoracic Society, Bronchoscopy International, and a series on YouTube by Dr. Henri Colt, though these tools are primarily on adult flexible bronchoscopy (https://www.thoracic.org/professionals/clinical-resources/video-lecture-series/bronchoscopy/; https://bronchoscopy.org; https://www.youtube.com/user/bronchorg%23p/c/29BD464130B411C6/0/phRv73Ik7fI). Studies in adult bronchoscopy training have shown variability in performance, and that procedure numbers are not a sufficient tool to assess competency. An expert panel on adult bronchoscopy training has suggested that "professional societies and certifying agencies move from a volume-based certification system to a standardized skill-acquisition and knowledge-based competency assessment for pulmonary and thoracic trainees."11 In contrast, there is as yet no consensus statement about assessing competency, nor a standardized competency assessment tool for pediatric flexible bronchoscopy. Computerized bronchoscopy simulators have been studied as a tool to develop competency (learning anatomy as well as manipulation of the bronchoscope). Several groups have reported that such simulation can result in the development of significant skills, and simulators can also provide a mechanism for assessing those skills, including attainment and maintenance of proficiency.12-15 There are online virtual bronchoscopy simulation tools available, as well as commercial products (http://pie.med.utoronto.ca/VB/VB_content/simulation.html; http://www.thoracic-anesthesia.com/?page_id=2; https://www.intelligentultrasound.com/orsim-5/orsim-6/). Simulation training in adult bronchoscopy has evolved. The American College of Chest Physicians (ACCP) has an innovative Bronchoscopy Certificate of Completion (COC) program designed for adult bronchoscopy, including cognitive as well as psychomotor skills for basic and advanced bronchoscopy involving transbronchial needle aspiration and endobronchial ultrasound utilizing simulation technology. The ACCP, with its Advanced Clinical Training Program, was the first society to receive accreditation from the Society for Simulation in Healthcare (https://www.chestnet.org/Education/Advanced-Clinical-Training/Certificate-of-Completion-Program/Bronchoscopy). The currently available virtual simulators, unfortunately, are not designed for pediatrics and are thus inadequate for pediatric training. In addition to virtual simulators, cheaper alternatives with simple inanimate models have been used. Recently, more sophisticated and realistic models for adult bronchoscopy training have been developed utilizing 3D-printed airways. There is also the potential of using a 3D model of a specific patient case for preprocedural training and planning.14, 16, 17 Before the pandemic, many pediatric pulmonary physicians had taken a formal course, which has been offered in the United States since 1981 by Wood and colleagues; similar courses have been offered by other groups in Europe and Asia. These courses have included lectures, video presentations of anatomy and pathologies, and demonstrations as well as hands-on experience in various nonhuman models, and have been a vital aspect of initial training. However, the pandemic has resulted in classroom and hands-on training opportunities being currently prohibited; it is unclear when traditional training can resume, despite the initiation of vaccine distribution. The didactic material from the Cincinnati Children's Hospital Medical Center (CCHMC) course is now available online, by subscription, but hands-on training will remain a significant problem for the immediate future. Traditionally, animal models have been used for initial training.18 However, due to societal pressure and other factors, despite its advantages, the use of live animals for training purposes has fallen out of favor. The development of inanimate models for medical training has been a quantum leap forward, but models currently available commercially have serious limitations. Other models, appropriate for pediatric training, have been reported, but these also have significant limitations.19, 20 Inanimate models do not move, breathe, cough, secrete mucus, bleed, or require constant monitoring of the physiologic state of the "patient". On the other hand, a realistic model can be very useful for learning anatomy, manipulation of the bronchoscope, development of manual skills, and in the hands of an experienced instructor can be powerful. However, no inanimate model, no matter how realistic, can be a complete replacement for hands-on experience in human subjects. At CCHMC, we have recently developed a high-fidelity model based on an 18-month-old child, using a combination of CT (computed tomography) scan data and artistic enhancement, guided by video recordings of pediatric bronchoscopy procedures and detailed iterative feedback from experienced pediatric bronchoscopists. This model includes the entire airway accessible to flexible bronchoscopes, from nostrils to 6th generation bronchi, and is anatomically highly accurate. There are realistic haptic qualities, and the model can be used for experience with bronchoalveolar lavage and clearing of secretions, as well as other interventional procedures. The first generation of this model was introduced for the 2019 Pediatric Flexible Bronchoscopy Course at CCHMC. Teaching with a model should involve more than the development of manual skills in driving the instrument. The addition of clinically relevant scenarios to challenge students can be not only stimulating but vital to establishing an approach for the performance of bronchoscopy in patients. The education of current and future trainees for pediatric flexible airway endoscopy is presently unsettled. The challenges of procedural medical training during the pandemic have necessitated different approaches to the traditional method of primarily apprentice training. In the relative absence of clinical experience, trainees will need more formalized didactic instruction regarding anatomy and pathology, as well as the basic psychomotor aspects of endoscopy. During this and any future pandemic or when a training program can offer only limited bronchoscopy experience, it is incumbent upon training directors to utilize all available opportunities for learning. These would specifically include models or simulators from our adult colleagues to give pediatric fellows the best possible training, even if this training is not specifically pediatric. This is a time of opportunity to capitalize on innovative solutions to adapt and improve future training, maintenance of cognitive knowledge, and psychomotor skills and their assessment, including developing standardized competency evaluation. Despite the pandemic, we must learn to bend the curve of training to adapt and progress. AUTHOR CONTRIBUTIONS Albin Leong: Conceptualization (equal); writing original draft (equal); writing review and editing (equal). Dan Benscoter: Writing review and editing (supporting). John Brewington: Writing review and editing (supporting). Cherie Torres-Silva: Writing review and editing (supporting). Robert E. Wood: Conceptualization (equal); writing original draft (equal); writing review and editing (equal). REFERENCES 1Gordon M, Patricio M, Horne L, et al. Developments in medical education in response to the COVID-19 pandemic: a rapid BEME systematic review: BEME Guide No. 63. Med Teach. 2020; 42: 1202- 1215. CrossrefPubMedWeb of Science®Google Scholar 2Mallon D, Pohl JF, NASPGHAN Training Committee COVID-19 Survey Working Group, et al. Impact of COVID-19 on Pediatric Gastroenterology Fellow Training in North America. J Pediatr Gastroenterol Nutr. 2020; 71: 6- 11. CrossrefCASPubMedWeb of Science®Google Scholar 3Pritchett MA, Oberg CL, Belanger A, et al. Society for Advanced Bronchoscopy Consensus Statement and Guidelines for bronchoscopy and airway management amid the COVID-19 pandemic. J Thorac Dis. 2020; 12: 1781- 1798. CrossrefPubMedWeb of Science®Google Scholar 4Lentz RJ, Colt H. Summarizing societal guidelines regarding bronchoscopy during the COVID-19 pandemic. Respirology. 2020; 25: 574- 577. Wiley Online LibraryPubMedWeb of Science®Google Scholar 5Wahidi MM, Shojaee S, Lamb CR, et al. The use of bronchoscopy during the coronavirus disease 2019 pandemic: CHEST/AABIP Guideline and Expert Panel Report. Chest. 2020; 158: 1268- 1281. CrossrefCASPubMedWeb of Science®Google Scholar 6McKechnie T, Levin M, Zhou K, Freedman B, Palter VN, Grantcharov TP. Virtual surgical training during COVID-19: operating room simulation platforms accessible from home. Ann Surg. 2020; 272: e153- e154. CrossrefPubMedWeb of Science®Google Scholar 7Chick RC, Clifton GT, Peace KM, et al. Using technology to maintain the education of residents during the COVID-19 pandemic. J Surg Educ. 2020; 77: 729- 732. CrossrefPubMedWeb of Science®Google Scholar 8García Vazquez A, Verde JM, Dal Mas F, et al. Image-guided surgical e-learning in the post-COVID-19 pandemic era: What is next? J Laparoendosc Adv Surg Tech A. 2020; 30: 993- 997. CrossrefPubMedWeb of Science®Google Scholar 9Leong AB, Green CG, Kurland G, Wood RE. A survey of training in pediatric flexible bronchoscopy. Pediatr Pulmonol. 2014; 49: 605- 610. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 10Faro A, Wood RE, American Thoracic Society Ad Hoc Committee on Flexible Airway Endoscopy in Children, et al. Official American Thoracic Society technical standards: flexible airway endoscopy in children. Am J Respir Crit Care Med. 2015; 191: 1066- 1080. CrossrefPubMedWeb of Science®Google Scholar 11Ernst A, Momen, Wahidi MM, et al. Adult bronchoscopy training: current state and suggestions for the future: CHEST Expert Panel Report. Chest. 2015; 148: 321- 332. CrossrefPubMedWeb of Science®Google Scholar 12Veaudor M, Gérinière L, Souquet P-J, et al. High-fidelity simulation self-training enables novice bronchoscopists to acquire basic bronchoscopy skills comparable to their moderately and highly experienced counterparts. BMC Med Educ. 2018; 18: 191. CrossrefPubMedWeb of Science®Google Scholar 13Kennedy CC, Maldonado F, Cook DA. Simulation-based bronchoscopy training: systematic review and meta-analysis. Chest. 2013; 144: 183- 192. CrossrefPubMedWeb of Science®Google Scholar 14Nilsson PM, Naur TMH, Clementsen PF, Konge L. Simulation in bronchoscopy: current and future perspectives. Adv Med Educ Pract. 2017; 8: 755- 760. CrossrefPubMedWeb of Science®Google Scholar 15Siddaiah-Subramanya M, Smith S, Lonie J. Mastery learning: how is it helpful? An analytical review. Adv Med Educ Pract. 2017; 8: 269- 275. CrossrefPubMedWeb of Science®Google Scholar 16Pedersen TH, Gysin J, Wegmann A, et al. A randomised, controlled trial evaluating a low cost, 3D-printed bronchoscopy simulator. Anaesthesia. 2017; 72: 1005- 1009. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 17Ho BHK, Chen CJ, Tan GJS, et al. Multi-material three dimensional printed models for simulation of bronchoscopy. BMC Med Educ. 2019; 19: 236. CrossrefPubMedWeb of Science®Google Scholar 18Wood RE, Pick JR. Model systems for teaching pediatric flexible bronchoscopy. Pediatr Pulmonol. 1990; 8: 168- 171. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar 19Hornung A, Kumpf M, Baden W, Tsiflikas I, Hofbeck M, Sieverding L. Realistic 3D-printed tracheobronchial tree model from a 1-year-old girl for pediatric bronchoscopy training. Respiration. 2017; 93: 293- 295. CrossrefPubMedWeb of Science®Google Scholar 20DeBoer EM, Wagner J, Kroehl ME, et al. Three-dimensional printed pediatric airway model improves novice learners' flexible bronchoscopy skills with minimal direct teaching from faculty. Simul Healthc. 2018; 13: 284- 288. CrossrefPubMedWeb of Science®Google Scholar Volume56, Issue6June 2021Pages 1386-1388 ReferencesRelatedInformation

Other than death of the patient, the most severe complication of a bronchoscopy is to have performed the procedure and obtained the wrong diagnostic impression or the wrong outcome. This chapter reviews some of the many ways things can go wrong and the traps awaiting the unwary or unprepared bronchoscopist.

The study of dynamic within-person personality responses using repeated measurement designs is emerging as a new focus in the study of personality at work, and offers great potential to build on and extend the large body of work on traits conducted by organizational researchers. In this chapter we provide a definition and discussion of dynamic personality and how it is both related to and differentiated from the trait approach in measurement and modelling. Both within-person and between-person variability in personality are considered worthy of study to gain insights into nomothetic principles. The cognitive-affective personality systems (CAPS) model provides a framework for modelling the underlying structure of dynamic personality responses as functions of situations, and provides an integration of the stable (between-person, nomothetic) and dynamic (within-person, idiographic and nomothetic) approaches to personality. This goes beyond the more fixed between-person approaches at contextualizing personality that capture context-related dynamics at the group level, such as trait activation theory and frame-of-reference studies. There are many big questions worthy of programs of research in this emerging field, which are the focus of the section “Challenges and future directions: where to from here?”

The asymptotic solutions for cracks in a linear elastic medium under plane or anti-plane state were obtained by Williams (1957) nearly sixty years ago. However, solutions for cracks in second-order elasticity are unavailable, in contrast to those based on the neo–Hookean models, e.g., Knowles (1997). This paper addresses the formulation and solution of crack problems under finite anti-plane deformation using higher-order elasticity. It is found that: (1) a combined second- and third-order elasticity is necessary to ensure that full equilibrium is satisfied, (2) the equilibrium equations are non-homogeneous partial differential equations (pde's) with variable coefficients, and (3) exact particular solutions can be obtained while the homogeneous pde's reduce to nonlinear eigenvalue problems that can be solved numerically. The results show that: (1) the displacement or stress dependence on the radial coordinate is generally a function of the elastic constants, (2) the Piola–Kirchhoff stress matrix is fully populated, with induced normal stresses, in-plane as well as out-of-plane shear stresses, (3) singular stresses at the crack tip may exist, depending on the eigenvalues, and (4) normal stresses are predicted on the crack faces, which may lead to anomalous mechanical behavior in soft biological materials.

Rationale: Complete tracheal ring deformity (CTRD) is a rare congenital abnormality of unknown etiology characterized by circumferentially continuous or nearly continuous cartilaginous tracheal rings, variable degrees of tracheal stenosis and/or shortening, and/or pulmonary arterial sling anomaly. Objectives: To test the hypothesis that CTRD is caused by inherited or de novo mutations in genes required for normal tracheal development. Methods: CTRD and normal tracheal tissues were examined microscopically to define the tracheal abnormalities present in CTRD. Whole-exome sequencing was performed in children with CTRD and their biological parents ("trio analysis") to identify gene variants in patients with CTRD. Mutations were confirmed by Sanger sequencing, and their potential impact on structure and/or function of encoded proteins was examined using human gene mutation databases. Relevance was further examined by comparison with the effects of targeted deletion of murine homologs important to tracheal development in mice. Measurements and Main Results: The trachealis muscle was absent in all of five patients with CTRD. Exome analysis identified six de novo, three recessive, and multiple compound-heterozygous or rare hemizygous variants in children with CTRD. De novo variants were identified in SHH (Sonic Hedgehog), and inherited variants were identified in HSPG2 (perlecan), ROR2 (receptor tyrosine kinase-like orphan receptor 2), and WLS (Wntless), genes involved in morphogenetic pathways known tomediate tracheoesophageal development in mice. Conclusions: The results of the present study demonstrate that absence of the trachealis muscle is associated with CTRD. Variants predicted to cause disease were identified in genes encoding Hedgehog and Wnt signaling pathway molecules, which are critical to cartilage formation and normal upper airway development in mice.

Employee relationships with supervisors can be based upon both work-focused activities and outcomes, as exemplified by leader-member exchange (LMX), and personal, non-work activities, as exemplified by Chinese guanxi. The purpose of this study is to examine the mediating role of supervisor-subordinate guanxi (SSG) and LMX in the relationship between the work-related human and social capital of employees and supervisors' ratings of their job performance. Data were collected from 372 employees and 127 supervisors in a range of companies in China. The study demonstrates how human and social capital might play differing roles in influencing SSG and LMX. In particular, LMX partially mediated the relationship between human capital and job performance, and the relationship between social capital and job performance was fully mediated by SSG and LMX. The findings enrich understanding of how personal capabilities influence work and non-work relationships and assessments of job performance. The unique content of the Chinese construct of guanxi has implications for research and practice in modern organizations where the barriers between work and non-work are permeable and relationships include affective attachment as well as instrumental considerations.

The purpose of this study was to investigate the personal factors that influence goal setting in the coaching process. In an experiment, we examined self-set goals as mediator and implicit theories of ability (ITA) as moderator of the impact of guidance versus facilitation styles of coaching on two types of performance, analogous and adaptive. Participants (n = 137) were coached to use one of two software programs, PowerPoint or Excel. We found that ITA moderated the mediating effects of self-set goals on the coaching style-performance relationship. Our findings support the importance of motivational fit by identifying the conditions under and process by which coaching enhances performance and adaptation. Implications for theory and management practice are discussed.

A cost-benefit calculus underlies most summary statements in the field, with a recognition that tourism brings both benefits and costs, and that public policy can affect the balance significantly. International tourism in the Third World was quite limited in the 1950s and 1960s when the development paradigm, that came to be known as modernisation theory, took shape. As with the sociology of development, the general drift in the sociology of tourism has been away from universal generalisations and towards an interest in documenting and explaining variation in the cultural consequences of tourism. The reorientation of cultural concerns in tourism studies has at once paralleled, been influenced by, and in some ways anticipated the broader rethinking of the meaning of culture that has often been characterised as ‘post-modernist’. International tourism neither ‘destroys’ culture nor does it ever simply ‘preserve’ it.

ObjectivesDevelop multidisciplinary and international consensus on patient, disease, procedural, and perioperative factors, as well as key outcome measures and complications, to be reported for pediatric airway reconstruction studies.MethodsStandard Delphi methods were applied. Participants proposed items in three categories: 1) patient/disease characteristics, 2) procedural/intraoperative/perioperative factors, and 3) outcome measures and complications. Both general and anatomic site‐specific measures were elicited. Participants also suggested specific operations to be encompassed by this project. We then used iterative ranking and review to develop consensus lists via a priori Delphi consensus criteria.ResultsThirty‐three pediatric airway experts from eight countries in North and South America, Europe, and Australia participated, representing otolaryngology (including International Pediatric Otolaryngology Group members), pulmonology, general surgery, and cardiothoracic surgery. Consensus led to inclusion of 19 operations comprising open expansion, resection, and slide procedures of the larynx, trachea, and bronchi as well as three endoscopic procedures. Consensus was achieved on multiple patient/comorbidity (10), disease/stenosis (7), perioperative‐/intraoperative‐/procedure‐related (16) factors. Consensus was reached on multiple outcome and complication measures, both general and site‐specific (8 general, 13 supraglottic, 15 glottic, 17 subglottic, 8 cervical tracheal, 12 thoracic tracheal). The group was able to clarify how each outcome should be measured, with specific instruments defined where applicable.ConclusionThis consensus statement provides a framework to communicate results consistently and reproducibly, facilitating meta‐analyses, quality improvement, transfer of information, and surgeon self‐assessment. It also clarifies expert opinion on which patient, disease, procedural, and outcome measures may be important to consider in any pediatric airway reconstruction patient.Level of Evidence5 Laryngoscope, 129:244–255, 2019

Aerodigestive programs provide coordinated interdisciplinary care to pediatric patients with complex congenital or acquired conditions affecting breathing, swallowing, and growth. Although there has been a proliferation of programs, as well as national meetings, interest groups and early research activity, there is, as of yet, no consensus definition of an aerodigestive patient, standardized structure, and functions of an aerodigestive program or a blueprint for research prioritization. The Delphi method was used by a multidisciplinary and multi-institutional panel of aerodigestive providers to obtain consensus on 4 broad content areas related to aerodigestive care: (1) definition of an aerodigestive patient, (2) essential construct and functions of an aerodigestive program, (3) identification of aerodigestive research priorities, and (4) evaluation and recognition of aerodigestive programs and future directions. After 3 iterations of survey, consensus was obtained by either a supermajority of 75% or stability in median ranking on 33 of 36 items. This included a standard definition of an aerodigestive patient, level of participation of specific pediatric disciplines in a program, essential components of the care cycle and functions of the program, feeding and swallowing assessment and therapy, procedural scope and volume, research priorities and outcome measures, certification, coding, and funding. We propose the first consensus definition of the aerodigestive care model with specific recommendations regarding associated personnel, infrastructure, research, and outcome measures. We hope that this may provide an initial framework to further standardize care, develop clinical guidelines, and improve outcomes for aerodigestive patients.

Should managers deliberately employ humor to persuade and motivate staff? A framework is presented for analyzing the role of humor in managerial communications. The framework includes the presenter, recipient, message and medium and elaborates cognitive and emotional reactions to humor by recipients. The framework is applied to analyses of the likely impacts of humor in problem solving and creativity. Facilitators and constraints for the effects of humor in managerial communications are discussed.

A 14-YR-OLD male with Morquio syndrome and complex airway anatomy presented for flexible bronchoscopy. Preoperative computed tomography with three-dimensional airway reconstruction revealed marked narrowing of the supraglottic and subglottic airway to 1.5 cm (solid and dashed arrows, image A). The trachea narrowed at C6 and remained in “saber-sheath” configuration for more than 5 cm to T3, with its center measuring 11 mm anteroposteriorly and 2 mm transversely.Saber-sheath trachea is characterized by widened anteroposterior diameter and a markedly narrowed transverse plane across the intrathoracic trachea1 (image B); it is uncommon and usually associated with chronic obstructive pulmonary disease, mediastinal mass compression, or ankylosing spondylitis.1,2 Difficulty in ventilation may be unanticipated because the trachea is narrowed but laryngoscopy is normal. The narrow trachea associated with saber-sheath deformities may require a smaller than predicted endotracheal tube (ETT); flexible bronchoscopy to guide the ETT tip to just above the narrowest part of trachea is recommended, as further advancement could cause tracheal mucosal injury. A smaller ETT may be used to bypass stenosis and may suffice for spontaneous ventilation.3If imaging suggests tracheal stenosis, maintenance of spontaneous ventilation and avoidance of muscle relaxants are recommended during induction of anesthesia. Attention should be given to the etiology, severity, and location of the deformity, as well as to measures that minimize air trapping.3The authors thank Dr. Robert Fleck, M.D., Department of Radiology, Cincinnati Children’s Hospital Medical Center, for his guidance with proper labeling of our image.This study was supported by Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio.The authors declare no competing interests.

OBJECTIVES:To describe the upper airway endoscopic findings of children with upper airway symptoms after liver transplantation (LT) or heart transplantation (HT).METHODS:Review of children undergoing airway endoscopy after LT or HT from 2011 to 2015 at a tertiary care pediatric hospital. Airway findings, biopsy results, immunosuppression, and Epstein-Barr virus (EBV) levels were recorded.RESULTS:Twenty-three of 158 LT (111) and HT (47) recipients underwent endoscopy. Median time from LT to endoscopy was 9 months (range 4-25) and 31 months (range 1-108) for HT. Thirteen of 23 patients presented with upper airway symptoms, and 10/23 presented with respiratory failure or for surveillance. Thirteen patients with upper airway symptoms had abnormal findings (7 LT; 6 HT), most commonly arytenoid edema (13 patients). There were five EBV-positive biopsies (four with post-transplant lymphoproliferative disorder), and six EBV-negative biopsies with lymphocytic inflammation. One biopsy demonstrated fungal infection. Immunosuppression was decreased in seven patients, and three received steroids. There were no episodes of allograft rejection. No patients had airway symptoms at last follow-up.CONCLUSIONS:In pediatric solid organ transplant recipients, symptoms of airway obstruction are not uncommon and should be evaluated with endoscopy. Endoscopy without symptoms is low-yield. Treatment with decreased immunosuppression improved airway symptoms.